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Direct
Ophthalmoscopy
“THE EYE IS A WINDOW TO
SYSTEMIC DISEASE”
Sandra Tubito, O.D.
July 2007
Discussion Outline
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Why ophthalmoscopy?
Types of ophthomoscopy
Direct ophthalmoscope
Examination Procedure
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Setting
External Exam
Internal Exam
What you should see
Pathology
Questions
Why ophthalmoscopy?
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Only way (and place in the body) that veins and
arteries can be seen in their natural state, noninvasively.
Part of general optical screening where direct
observation of the structures of the fundus may
show:
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Disease of the eye itself (e.g. glaucoma, retinal
detachment)
Abnormalities indicative of disease elsewhere in the body
(e.g. diabetes, hypertension)
Evaluation of ocular complaints
Types of Ophthalmoscopes
Direct ophthalmoscope
Indirect ophthalmoscope
Types of Ophthalmoscopes
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Direct
X15 magnification
 10° field of view
 Real image
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Monocular
 Undilated pupil
 Maximum
resolution of 70µm
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Indirect
X2-3 magnification
 30° field of view
 Inverted and upside down
image
 Binocular
 Dilated pupil
 Maximum resolution of
200µm
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Direct Ophthalmoscope
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Illuminating system
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Light bulb
Lenses
Reflector
Aperture stops and filters
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Different sized stops to change
illumination of the retina
Green (red free) filter
Viewing system
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Sight hole (3mm in diameter)
Focusing lenses
Direct Ophthalmoscope
Examination Procedure
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Setting
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Dark room
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Seat patient in comfortable chair with head rest
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Ask patient to look at a slightly elevated target on
opposite wall
Examination Procedure
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External Exam
Look at R eye with R eye
(L with L)
 Place hand on shoulder or
forehead
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Change viewing angle to
15° to avoid light reflex of
cornea
Examination Procedure
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External Exam
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Red Reflex - hold ophthalmoscope
at ~50cm and look through sight
hole at the ocular media. Find the
red reflex in the pupil. Opacities
(eg cataracts) can be seen.
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Place +8.00D lens in sight hole and
move to ~10cm to inspect anterior
structures:
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lids/lashes
conjunctiva
cornea
Examination Procedure
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Internal Exam
Turn focus wheel to bring
anterior chamber and iris into
focus
 Gradually reduce power in
ophthalmoscope to focus on
internal structures:
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Lens
Vitreous
Retina
Examination Procedure
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Internal Exam
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Continue turning focus wheel
to bring retina/vessels in focus
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Follow the vessels to the disc
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The ‘arrow’ point to the disc
Examine the disc, vessels,
retina, & macula.
Things you should see
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The optic nerve head
Appearance – shape/size
(1.5mm in diameter)
 Color – disc is pale pink, cup is
whitish
 Elevation – should be flat
 Rim – clear and distinct
 Cup/Disc ratio
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Ratio of the diameter of the cup
to the diameter of the disc
Cup /Disc ratio
Things you should see
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Retinal vessels
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Arteries
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Veins
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Darker in color, larger
May spontaneously pulsate at the disc
(80%)
The ratio of the artery :vein diameter is
normally ~ 2:3
Follow vessels from disc
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Lighter in color, smaller
Look at arterio-venous crossings for
abnormalities (nicking, compression,
elevation, deviation)
Check arterial light reflex. This will get
whiter and thicker in arteriosclerosis
Arteriovenous changes
Tapering concealment of the vein
appearing as ‘nicking’
Deviation of the vein out of its path
Elevation of the vein over the artery
Compression of the vein at the
arterio-venous crossing, causing
stenosis of the distal vein
Things you should see
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Retina
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Check the background retina
Look for color differences
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areas of hyper or hypo pigmentation
Scarring
Raised areas
Hemorrhages, microaneurisms
Cotton wool exudates
Hard exudates
A more peripheral view can be
obtained by having the patient look in
different directions
OD
OS
Things you should see
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Fovea and Macula
 Change sight hole to the
smallest aperature
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Have patient look at the light
Temporal and slightly inferior to
the disc
Slightly darker than rest of retina
Central depression/reflex - fovea
Pathology - The optic nerve
Optic atrophy
Pathology - The optic nerve
“Choked disc”
or
Papilledema
Pathology – The optic nerve
Glaucomatous cupping
Pathology - The optic nerve
Papilledema with
papillary hemorrhages
Disc neovascularization
Pathology – Retina / Vessels
Arterial
occlusions
Pathology – Retina / Vessels
Circinate exudates
Pathology – Retina / Vessels
Intra-retinal hemorrhages
Pathology – Retina / Vessels
Cotton wool spots
Pathology – Retina / Vessels
Neovascularization
Pathology - Retina / Vessels
Arterial plaques
Pathology – Retina / Vessels
Venous occlusions
Pathology - Macula
Drusen
Pathology - Macula
Age related macula degeneration
Hemorrhagic phase
Pathology - Macula
Exudative age related macular degeration
QUESTIONS?